Provider Demographics
NPI:1881142925
Name:THOMPSON, BRIAN (CRC)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:CRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:238 W 4TH ST APT 1A
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10014-2688
Mailing Address - Country:US
Mailing Address - Phone:646-204-1431
Mailing Address - Fax:
Practice Address - Street 1:5 W 86TH ST APT 1A
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10024-3663
Practice Address - Country:US
Practice Address - Phone:646-204-1431
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-19
Last Update Date:2016-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL00137167101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)